The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST MARY'S MEDICAL CENTER 901 45TH ST WEST PALM BEACH, FL 33407 June 13, 2019
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on staff interview, administrative and clinical record review, the facility failed to ensure thorough communication of the discharge instructions was provided regarding all the patient's discharge needs for 1 of 3 sampled patients (Patient # 1) to ensure implementation of an effective discharge plan.

The findings included


Review of the Discharge Planning for Patient # 1 revealed communication with the Assisted Living Facility regarding the patient's wound care needs secondary to the previous burn the patient sustained prior to admission to the hospital. However, there is no evidence the Discharge Planner communicated with the ALF regarding the patient new diagnosis of Diabetes and the patient's care needs associated with this new diagnosis. Further review of the twice daily nursing assessments did not provide evidence the patient received education/training specifically regarding insulin administration, storage and glucose monitoring and performance of the accuchecks for a newly diagnosed diabetic. Nor was there indication whether the patient was provided a prescription for and/or the necessary monitoring equipment to perform the prescribed glucose monitoring.

An interview was conducted with the Risk Manager on 06/06/19 at 3:30 PM. She confirmed that newly diagnosed diabetic patients are referred to the Diabetic Educator for teaching and training. But she confirmed that Patient # 1 was not referred to the Diabetic Educator. Additionally, she confirmed the nursing assessment did not specifically address whether the patient received the appropriate teaching and training regarding his new diagnosis and/or provision of care and services for his new diabetic diagnosis. The nurses responsible for providing care and services for the patient on the day of discharge were unavailable for interview.

The patient presented to the hospital with the chief complaint of not feeling well. The patient was later diagnosed with Diabetes. The patient was being discharge on insulin isophane-insulin regular (insulin isophane-insulin regular human recombinant) 70/30 units units/ml subcutaneous twice daily before meals. There was no specific dose noted on these instructions. Also the patient was prescribed insulin regular (insulin regular human recombinant) 100 units/ml sliding scale # 2 subcutaneous three times daily before meals and at bedtime. There is no documentation of the actual sliding scale amounts indicated.

The 11/26/18 5:22 PM Discharge Instructions noted a discharge diagnoses of Acute Hyperglycemia, Anemia, Burn on neck, Dehydration, Schizophrenia and Syncope. The orders on the instructions included "Discharge home; diet ADA/Diabetic and comment of "d/c to ALF vs SNF per wound care recommendations follow up with the PC within a week." There was no notation about the new medications prescribed to treat the patient's new diagnosis of Diabetes nor does the instructions provide provision for home health or how the provision of care and services for the insulin injections and/or the glucose monitoring. Additionally, there was no indication, the patient was provided the appropriate teaching and training to self-administer the insulin. There was no evidence of diabetic teaching for the newly diagnosed diabetic patient and it was not apparent that home health was informed of the new diagnosis to provide some initial monitoring and evaluation of the patient's capability to provide the necessary care and services for his new diagnosis.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and administrative and clinical record review, the facility failed to ensure that 1 of 3 sampled patients (Patient # 1) had an appropriate reassessment to address the discharge plan to include provisions of care and services to meet the newly identified patient's discharge needs.

The findings included:

Review of the clinical record for Patient # 1 revealed that the patient presented to the facility's emergency room on [DATE] with a chief complaint of not feeling well. The patient was found to have a blood glucose of 800. According to the patient's history and physical, he had a history of schizophrenia, hepatitis and hypertension. The patient recently sustained a burn to the left side of his neck. The patient also complained of feeling weak and was found to have a low hemoglobin and received a transfusion. The physician's assessment included the patient was "newly diagnosed diabetes". The patient was admitted to the facility and started on an insulin drip. The plan included "will eventually start patient on insulin regimen, regular insulin sliding scale and insulin drip. They will "discharge the patient once his blood glucose is better controlled."

The Discharge Planner completed the patient's initial assessment on 11/25/18 and noted that the patient previously lived in an Assisted Living Facility (ALF) and noted that the patient was able to provide self-care; care needs over time are expected to lessen and only identified one area regarding the patient's high risk screening criteria which was the patient had chronic conditions of diagnoses such as Heart Failure, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Cancer, Diabetes and/or Dementia. The Discharge Planner did not identify issues concerning "the patient had any Behavioral health/Compliance; lack of financial/social support; medication management; patient or caregiver has low degree of understanding regarding how to manage illness or any non-compliance with the plan of care" for a newly diagnosed insulin-dependent diabetic.
However, on 11/26/18, the Discharge Planner noted the patient's final discharge disposition was home with self-care with relative, group home, foster care, self-administer (IV) intravenous, homeless, RC, board and care, ALF. She further noted that she spoke with the ALF, "they stated patient already receives wound care services. They will pick up." There is no indication, the Discharge Planner, reassessed the patient regarding his current needs and new diagnosis. There was no mention or identification of the provision of care and services for a newly diagnosed , insulin dependent diabetic. Additionally there was no indication the ALF was made aware of the new Diabetes Diagnosis; medication and treatment changes in the patient's care needs for insulin administration, monitoring and administration of medication for the patient's blood glucose checks. The patient was being discharged to an Assisted Living Facility without the licensed capability of providing extended nursing care services for the provision of care for the insulin injections and accuchecks.
The patient was also noted to be confused and there is no indication the patient was capable of managing his diabetes regarding the injections and glucose monitoring without medical/nursing assistance.

An interview was conducted on 06/06/19 at approximately 1:30 PM with the Director of Discharge Planning. The Discharge Coordinators assigned to the patient were unavailable. The Director stated the Discharge Planners attempt to complete the initial evaluation of the patient within 24-48 hours of admission to the hospital. Though she was not the worker specifically assigned to the patient's care, she was unaware that the ALF was not licensed to provide the care and services currently needed by the patient without the interventions of the Home Health Agency. It is also not apparent that the patient was evaluated and/or trained to provide the care and services required for a newly diagnosed diabetic. She further stated from the discharge planner's note, the patient's plan was focused on the wound care and did not include the patient's new needs for care and services for his diabetes.

Review of the physician discharge orders revealed orders prescribing glipizide 5 mg oral tablet one tablet twice daily before meals; insulin isophane-insulin regular (insulin isophane-insulin regular human recombinant) 70/30 units units/ml subcutaneous twice daily before meals. However, there is no specific dose noted on these orders. Also the patient was prescribed insulin regular (insulin regular human recombinant) 100 units/ml sliding scale # 2 subcutaneous three times daily before meals and at bedtime. Additionally, there is no documentation of the actual sliding scale amounts indicated.

The patient was discharged on [DATE] and was readmitted on [DATE] with an elevated blood sugar. It also should be noted on the review of the Medication Administration Record (MAR) sent from the ALF with the patient, the MAR did not document any hyperglycemic medications previously prescribed for the patient.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, administrative and clinical record review, the facility failed to ensure 1 of 3 sampled patients ( Patient # 1) received the necessary referrals for patient and caregiver information, education and medical equipment for a patient with a new diagnosis of diabetes to ensure an effective discharge plan was provided.

The findings included:

The clinical record for Patient # 1 revealed the patient was admitted to the facility on [DATE] at 1:00 PM and was discharged on [DATE] at 5:00 PM. The patient was initially admitted to the Intensive Care Unit on an insulin drip and remained there until 11/25/18 and was then transferred to acute care medical surgical unit.
Further review of the twice daily nursing assessments did not provide evidence the patient received education/training specifically regarding insulin administration, storage and glucose monitoring and performance of the accuchecks for a newly diagnosed diabetic. Nor was there indication whether the patient was provided a prescription for and/or the necessary monitoring equipment to perform the prescribed glucose monitoring.

An interview was conducted with the Risk Manager on 06/06/19 at 3:30 PM. She confirmed that newly diagnosed diabetic patients are referred to the Diabetic Educator for teaching and training. But she confirmed that Patient # 1 was not referred to the Diabetic Educator. Additionally, she confirmed the nursing assessment did not specifically address whether the patient received the appropriate teaching and training regarding his new diagnosis and/or provision of care and services for his new diabetic diagnosis. The nurses responsible for providing care and services for the patient on the day of discharge were unavailable for interview.

Additionally, review of the discharge planning notes, evaluations and instructions did not provide evidence of the patient's new diagnosis of Diabetes and the specific care needs of insulin administration and glucose monitoring was not documented as conveyed to the caregiver, Assisted Living Facility. Nor how the provision of care would be provided for the newly diagnosed diabetic patient.
On 11/26/18, the Discharge Planner noted the patient's final discharge disposition was home with self-care with relative, group home, foster care, self-administer (IV) intravenous, homeless, RC, board and care, ALF. She further noted that she spoke with the ALF, "they stated patient already receives wound care services. They will pick up." Again, there was no mention or identification of the provision of care and services for a newly diagnosed , insulin dependent diabetic. Additionally there was no indication that the ALF was made aware of the new Diabetes Diagnosis; medication and treatment changes in the patient's care needs for insulin administration, monitoring and administration of medication for the patient's blood glucose checks. The patient was being discharged to an Assisted Living Facility without the licensed capability of providing extended nursing care services for the provision of care for the insulin injections and accuchecks. There was no evidence the facility made the appropriate referral to the Home Health Agency to include care and services for the patient new needs for Diabetic care and medical equipment and supplies for continued diabetic management.